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Home , Epididymis, Epididymitis, Fournier gangrene, Orchitis, Scrotum, Testicular pain

Clinical Prevention Services Provincial STI Services 655 West 12th Avenue Vancouver, BC V5Z 4R4

Tel : 604.707.5600 Fax: 604.707.5604 www.bccdc.ca

BCCDC Non-certified Practice Decision Support Tool EPIDIDYMITIS

Testicular torsion is a surgical emergency and requires immediate consultation. It can mimic epididymitis and must be considered in all people presenting with sudden onset, severe testicular . Males less than 20 years are more likely to be diagnosed with , but it can occur at any age. Viability of the testis can be compromised as soon as 6-12 hours after the onset of sudden and severe . SCOPE RNs must consult with or refer all suspect cases of epididymitis to a physician (MD) or nurse practitioner (NP) for clinical evaluation and a client-specific order for empiric treatment.

ETIOLOGY Epididymitis is of the , with bacterial and non-bacterial causes:

Bacterial:  trachomatis (CT)  (GC)  coliforms (e.g., E.coli)

Non-bacterial:  urologic conditions  trauma (e.g., )  autoimmune conditions, and (not as common)

EPIDEMIOLOGY

Risk Factors STI-related:  condomless insertive  recent CT/GC or UTI

BCCDC Clinical Prevention Services Decision Support Tool – Non-certified Practice 1 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

Other considerations:  recent urinary tract instrumentation or surgery  obstructive anatomic abnormalities (e.g., benign prostatic hyperplasia (BPH))

The following risk factors are more commonly seen in chronic epididymitis:  trauma or strenuous physical activity  sitting for prolonged periods of time (e.g., riding a bicycle or motorcycle)  prior scrotal or inguinal  history of recent instrumentation, , Beçhet’s disease, travel to areas endemic for or viral illness (e.g., mumps)  that can cause epididymitis (e.g., amiodarone)

CLINICAL PRESENTATION  relatively quick onset of epididymal and/or testicular pain  tenderness and swelling of epididymis, testis and/or (usually unilateral)  symptoms of (, increased frequency, urgency)  symptoms of (dysuria, urethral itch, irritation or awareness, meatal erythema or urethral discharge)  is occasionally present

PHYSICAL ASSESSMENT Physical assessment specific to epididymitis may include the following:  assess the epididymis, testis and scrotum for pain and swelling  assess the scrotum for erythema  note any urethral discharge (can ask the client to “milk” the )  note the anatomic position of testis  palpate inguinal area for  assess for Fournier’s ( of the ; can see acute scrotal swelling, severe pain in anterior abdominal wall spreading to gluteal muscles, scrotum and penis)  assess temperature

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 2 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

Practitioner Alert!

Testicular torsion is a surgical emergency and requires immediate consultation.

DIAGNOSTIC AND SCREENING TESTS If urethral discharge is present, collect swab(s) for:  GC culture and sensitivity (C&S)  CT/GC NAAT swab If urethral discharge is not present, collect a urine specimen for CT/GC NAAT.

If enteric infection(s) or genitourinary suspected:  collect urine specimen for dipstick o order urine culture if: . dipstick positive for leukocytes, nitrites and/or blood . dipstick negative, but symptomatic with urethral symptoms A MD or NP may order an ultrasound (U/S) or do a digital rectal examination to help clarify a diagnosis. Arranging to get an U/S should not delay an urgent surgical consult if testicular torsion is suspected.

MANAGEMENT

Diagnosis and Clinical Evaluation RNs must consult or refer all suspect cases of epididymitis to a MD or NP for clinical evaluation and a client-specific order for empiric treatment.

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 3 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

Consultation and Referral All suspect cases of epididymitis must be referred to a MD or NP for evaluation and a client- specific order for empiric treatment.

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 4 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

Treatment Recommended treatment options for reflect both current local antimicrobial resistance trends (see BCCDC Laboratory Trends Newsletters) and national STI guidelines.

RNs must consult or refer all suspect cases of epididymitis to a MD or NP for clinical evaluation and a client-specific order for empiric treatment.

Treatment Notes

If condomless insertive anal sex, treat 1. Treatment for epididymitis CT/GC . for enteric pathogens and provide CT/GC coverage 2. Review information on the BCCDC Handouts and your agency’s drug reference database, 800 mg PO in a single dose including: AND  Allergies, interactions and side effects fluoroquinolone (e.g., )  How to take the medication  After-care information 250 mg IM in a single dose 3. Cefixime AND  DO NOT USE if allergy to cephalosporins. fluoroquinolone (e.g., levofloxacin)  Consult with or refer to MD or NP if history of anaphylaxis or immediate reaction to . If < 35 years and no condomless insertive anal sex, treat for CT/GC 4. Ceftriaxone infection  DO NOT USE if allergy to cephalosporins. cefixime 800 mg PO in a single dose  To minimize discomfort, use 0.9ml lidocaine 1% (without epinephrine) as the diluent for ceftriaxone IM. AND  Ventrogluteal site is preferred. 100 mg PO BID for 10 days  Review potential for side effects: pain, redness and swelling at the injection site, or diarrhea. If these persist ceftriaxone 250 mg IM in a single dose or worsen, advise to contact a provider. AND 5. Lidocaine doxycycline 100 mg PO BID for 10 days  DO NOT USE if allergy to local anaesthetics. If ≥ 35 years and no condomless 6. Doxycycline insertive anal sex, cover enteric pathogens  DO NOT USE if allergy to doxycycline or other tetracyclines. fluoroquinolone (e.g., levofloxacin)  Take with food/water to avoid potential adverse gastrointestinal effects.  RE-TREAT if 2 consecutive doses are missed within the first 5 days of treatment, or if 5 days of treatment is not completed. 7. Fluroquinolones: provide CT coverage (e.g., levofloxacin). MD/NPs can check local antibiograms (e.g., BCCDC, Lifelabs).

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 5 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

Monitoring and Follow-up  Repeat testing: No  Test-of-cure (TOC): No  Follow-up: if test results are positive for CT/GC, review MD/NP treatment and follow- up plan, and confirm client received adequate treatment for the infection(s)

Partner Counselling and Referral  Reportable: No If CT/GC infection is confirmed, refer to the appropriate DST for partner counselling and referral information.  Trace-back period: last 60 days. If no partners during this time, last sexual contact  Recommended partner follow-up: if CT/GC is the confirmed or suspected cause, empirically test and treat all contacts (see the Treatment of STI Contacts DST)

Potential Complications  chronic epididymitis   testicular  testicular

Additional Client Education Counsel client:  that pain and erythema should resolve within 3 to 7 days.  that it could take a few weeks after the completion of for symptoms to completely resolve, although should see improvement during first week of therapy.  to complete all treatment as directed even if symptoms improve or resolve.  to avoid sexual contact until the client and their partner(s) have completed screening and treatment, and symptoms have resolved.  to use of (e.g., NSAIDs), rest and scrotal elevation to help alleviate pain  Standard Client Education for Sexually Transmitted Infections and Blood-Borne Infections (STBBI)

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 6 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

REFERENCES Al-Kandari AM, Kehinde EO, Khudair S, Ibrahim H, ElSheemy MS, Shokeir AA. Intermittent Testicular Torsion in Adults: An Overlooked Clinical Condition. Medical principles and practice : international journal of the Kuwait University, Health Science Centre. 2017;26(1):30–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5588398/. Australasian Sexual Health Alliance (ASHA). Australian STI management guidelines for use in primary care. Epididymo-. 2018. Available from: http://sti.guidelines.org.au/syndromes/epididymo-orchitis. Bradford R, Farry S, Kyle JA. Therapy for Epididymitis. U.S. Pharm. 2015:40(8):39- 43. Available from: https://www.uspharmacist.com/article/antibiotic-therapy-for- epididymitis. British Columbia Centre for Disease Control (BCCDC). British Columbia Treatment Guidelines. Sexually Transmitted Infections in Adolescent and Adults. STI/HIV Prevention and Control Division, BC Centre for Disease Control. 2014. Capet J, Sønsksen J, Bisbjerg R, Fode M. Is follow-up ultrasound necessary after acute epididymitis? A retrospective analysis from a large university hospital. Scandinavian Journal Of . 2018;52(5-6):445-7. Centers for Disease Control and Prevention (CDC). Sexually Transmitted Diseases Treatment Guidelines. Morbidity and Mortality Weekly Report. June 5, 2015. Available from: https://www.cdc.gov/std/tg2015/tg-2015-print.pdf. Chen JZ, Gratrix J, Brandley J, Smyczek P, Parker P, Read R, et al. Retrospective Review of Gonococcal and Chlamydial Cases of Epididymitis at 2 Canadian Sexually Transmitted Infection Clinics, 2004-2014. Sexually Transmitted Diseases. 2017;44(6):359-61. Eyre R, O'Leary M, Givens J. Evaluation of acute scrotal pain in adults. UpToDate. 2019. Ito S, Tsuchiya T, Yasuda M, Yokoi S, Nakano M, Deguchi T. Prevalence of genital and ureaplasmas in men younger than 40 years-of-age with acute epididymitis. International Journal Of Urology: Official Journal Of The Japanese Urological Association. 2012;19(3):234-8. Farber NJ, Slater RC, Maranchie JK. Multidrug resistant epididymitis progressing to testicular infarct and . Case reports in urology. 2013;2013:645787. Available from: https://doi.org/10.1155/2013/645787. Jarvi KA, Wu C, Nickel JC, Domes T, Grantmyre J, Zini A. Canadian Urological Association best practice report on chronic scrotal pain. Canadian Urological Association Journal = Journal De L'association Des Urologues Du Canada. 2018;12(6):161-72. Lampejo T, Abdulcadir M, Day S. Retrospective review of the management of epididymo- orchitis in a London-based level 3 : an audit of clinical practice. International Journal Of STD & AIDS. 2017;28(10):1038-40. Louette A, Krahn J, Caine V, Ha S, Lau TTY, Singh AE. Treatment of Acute Epididymitis: A Systematic Review and Discussion of the Implications for Treatment Based on Etiology. Sexually Transmitted Diseases. 2018;45(12):e104-e8.

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 7 Epididymitis 2020

BCCDC Non-certified Practice Decision Support Tool Epididymitis

McConaghy JR, Panchal B. Epididymitis: An Overview. American family physician. 2016;94(9):723-6. Pilatz A, Hossain H, Kaiser R, Mankertz A, Schüttler CG, Domann E, et al. Acute epididymitis revisited: impact of molecular diagnostics on etiology and contemporary guideline recommendations. European Urology. 2015;68(3):428-35. Public Health Agency of Canada (PHAC). Canadian Guidelines on Sexually Transmitted Infections. Supplementary Statement for Recommendations Related to the Diagnosis, Management and Follow-Up of Epididymitis. 2014. Available from: http://www.phac- aspc.gc.ca/std-mts/sti-its/cgsti-ldcits/assets/pdf/epid-eng.pdf. PHAC. Epididymitis. Canadian Guidelines on Sexually Transmitted Infections. 2008. Available from: https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health- sexually-transmitted-infections/canadian-guidelines/sexually-transmitted- infections/canadian-guidelines-sexually-transmitted-infections-20.html. Stewart A, Ubee SS, Davies H. 10-minute consultation: Epididymo-orchitis. BMJ. 2011;342(7803):923-5. Street EJ, Justice ED, Kopa Z, Portman MD, Ross JD, Skerlev M, et al. The 2016 European guideline on the management of epididymo-orchitis. International Journal Of STD & AIDS. 2017;28(8):744-9. Street E, Joyce A, Wilson J. BASHH UK guideline for the management of epididymo-orchitis, 2010. International journal of STD & AIDS. 2011;22(7):361–5. Available from: https://doi.org/10.1258/ijsa.2011.011023. Tracy CR, Costabile RA. The evaluation and treatment of acute epididymitis in a large university based population: are CDC guidelines being followed? World Journal Of Urology. 2009;27(2):259-63. Trojian TH, Lishnak TS, Heiman D. Epididymitis and orchitis: an overview. American family physician. 2009 Apr 1;79(7):583–7. Wright S, Hoffmann B. of acute scrotal pain. European journal of : official journal of the European Society for Emergency Medicine. 2015 Feb 22(1):2–9.

BCCDC Clinical Prevention Services Reproductive Health Decision Support Tool – Non-certified Practice 8 Epididymitis 2020